Medicare and Medicaid fraud cost American taxpayers some $54 billion last year. (We've long believed that Medicare fraud is the unofficial state sport of Florida.) CMS has tried many approaches to catching some of the perpetrators, notably through the Recovery Audit Contractor program, but the bad guys always seem to be one step ahead of the G-men.
The Obama administration wants to go high-tech in its pursuit of fraudsters, sending out "bounty hunter auditors" to find waste, fraud and abuse in Medicare and Medicaid, according to the Huffington Post.
"We're told the auditor's weapons will be sophisticated new computer programs to scan Medicare and Medicaid billing records nationwide to check for patterns of bogus claims," writes columnist Diane Dimond. "And like the early bounty hunters of the old West these modern day crime fighters will get to keep a percentage of what they recoup for taxpayers. It seems like a win-win idea. Pilot programs in California, New York and Texas over the last three years re-captured $900 million that would have otherwise gone into the crook's pockets."
The administration estimates such cybersleuths could recover at least $2 billion in wasteful and fraudulent spending over the next three years. If fraud continues at its current pace, that's less than 1.5 percent of the $162 billion CMS will squander in that three-year period, but hey, it's a start, right?
FierceHealthCare IT
10-22-2010
Friday, October 22, 2010
Company Used Dementia Patients In $200M Medicare Scam
In what Justice Department officials are calling the largest fraudulent billing plot ever prosecuted by by a healthcare fraud strike force, HHS and FBI agents arrested four people--Lawrence Duran, Marianella Valera, Judith Negron and Margarita Acevedo-- for their alleged role in masterminding an unprecedented plot to defraud the Medicare program of close to $200 million.
The people involved were owners and senior managers of American Therapeutic Corporation (ATC) and Medlink Professional Management Group, Inc. The business model of the two Miami-based businesses was Medicare fraud. The companies allegedly netted $83 million in illicit payments from Medicare since 2003, The Christian Science Monitor reports. The four people and two companies were charged in a 13-count indictment for billing Medicare for community-based mental health services that were unnecessary or never actually provided.
The alleged illegal conduct in the indictment is "unlike anything we've seen before in terms of the nature and size of the scheme," Assistant Attorney General, Lanny Breuer said in a statement yesterday.
Unlike so much Medicare fraud that involves medical equipment and services, this case involves Medicare's Partial Hospitalization program, which gives mental health patients much-needed services in outpatient settings.
ATC and other defendants preyed on some of the most vulnerable patients, paying kickbacks to owners and operators of assisted living facilities and halfway houses in exchange for patient referrals. At ATC branches, bogus mental health therapy sessions were organized where elderly and infirm patients were left in rooms for hours, and received no legitimate or medically necessary therapy. Some of the patients suffered from Alzheimer's disease or dementia, and did not even know where they were. Others simply came to make money through kickbacks.
Some of the defendants were also charged with having "charting parties," where senior managers met regularly to write up fake patient medical charts.
Patient recruiters would find people who needed a place to stay overnight and offer them free temporary housing, cash or other bribes in exchange for agreeing to pose as patients.
Since the inception of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) to fight Medicare fraud in 2007, Strike Force operations have led to charges against more than 825 defendants who falsely billed Medicare for more than $2 billion.
FierceHealthCare
10-22-2010
The people involved were owners and senior managers of American Therapeutic Corporation (ATC) and Medlink Professional Management Group, Inc. The business model of the two Miami-based businesses was Medicare fraud. The companies allegedly netted $83 million in illicit payments from Medicare since 2003, The Christian Science Monitor reports. The four people and two companies were charged in a 13-count indictment for billing Medicare for community-based mental health services that were unnecessary or never actually provided.
The alleged illegal conduct in the indictment is "unlike anything we've seen before in terms of the nature and size of the scheme," Assistant Attorney General, Lanny Breuer said in a statement yesterday.
Unlike so much Medicare fraud that involves medical equipment and services, this case involves Medicare's Partial Hospitalization program, which gives mental health patients much-needed services in outpatient settings.
ATC and other defendants preyed on some of the most vulnerable patients, paying kickbacks to owners and operators of assisted living facilities and halfway houses in exchange for patient referrals. At ATC branches, bogus mental health therapy sessions were organized where elderly and infirm patients were left in rooms for hours, and received no legitimate or medically necessary therapy. Some of the patients suffered from Alzheimer's disease or dementia, and did not even know where they were. Others simply came to make money through kickbacks.
Some of the defendants were also charged with having "charting parties," where senior managers met regularly to write up fake patient medical charts.
Patient recruiters would find people who needed a place to stay overnight and offer them free temporary housing, cash or other bribes in exchange for agreeing to pose as patients.
Since the inception of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) to fight Medicare fraud in 2007, Strike Force operations have led to charges against more than 825 defendants who falsely billed Medicare for more than $2 billion.
FierceHealthCare
10-22-2010
Monday, October 18, 2010
Obesity-Related Medical Costs Double Earlier Findings
Spending on obesity is worse than we thought. A National Bureau of Economic Research study found that obesity actually accounts for 17 percent of all medical costs annually, as opposed to 9 percent as previously determined last year.
The NBER research, conducted by John Cawley of Cornell University and Chad Meyerhoefer of Lehigh University, concluded medical costs in relation to obesity are closer to $170 billion per year than $150 billion due in large part to understated self-reporting and overly cautious research gathering, reports the Associated Press. The new report tries to take both factors into account and adjusts the statistics accordingly via balanced "repeated replications to estimate standard errors," the study's authors write.
"The authors tried to better establish that excess weight was a cause for medical costs," the AP reports. "Previous studies stopped short of saying obesity caused the costs because there was too great a chance other factors could be responsible."
The researchers compiled statistics from the exact same database used to come up with the $150 billion figure, which included information on 24,000 non-elderly adults gathered from 2000 to 2005. While the earlier estimate determined that obesity added $1,400 to a person's annual medical bill, the new calculations found that number to be more than $2,800.
Cawley and Meyerhoefer point out that the motivation behind their research is not to push for more funding related to the treatment of obesity, but simply to inform. "This paper does not estimate the medical care cost of obesity in order to argue that treatment of obesity should be prioritized above treatment of other conditions, but so that the medical care consequences of obesity will be more accurately known," they write.
FierceHealthCare
10-18-2010
The NBER research, conducted by John Cawley of Cornell University and Chad Meyerhoefer of Lehigh University, concluded medical costs in relation to obesity are closer to $170 billion per year than $150 billion due in large part to understated self-reporting and overly cautious research gathering, reports the Associated Press. The new report tries to take both factors into account and adjusts the statistics accordingly via balanced "repeated replications to estimate standard errors," the study's authors write.
"The authors tried to better establish that excess weight was a cause for medical costs," the AP reports. "Previous studies stopped short of saying obesity caused the costs because there was too great a chance other factors could be responsible."
The researchers compiled statistics from the exact same database used to come up with the $150 billion figure, which included information on 24,000 non-elderly adults gathered from 2000 to 2005. While the earlier estimate determined that obesity added $1,400 to a person's annual medical bill, the new calculations found that number to be more than $2,800.
Cawley and Meyerhoefer point out that the motivation behind their research is not to push for more funding related to the treatment of obesity, but simply to inform. "This paper does not estimate the medical care cost of obesity in order to argue that treatment of obesity should be prioritized above treatment of other conditions, but so that the medical care consequences of obesity will be more accurately known," they write.
FierceHealthCare
10-18-2010
Most Expensive Hospital Stays Cost About $18,000 A Day
The priciest hospital stays are also among the most futile. Among the top 0.5 percent of most expensive hospital stays, the average length of stay runs about 48 days and costs more than $500,000, yet more than eight in 10 of the patients involved face a major or extreme chance of dying, regardless.
This finding comes from data in Agency for Healthcare Research and Quality's newly released report, Most Expensive Hospitalizations, 2008, which uses data from a database of hospital inpatient stays in all short-term, non-Federal hospitals. Data are drawn from hospitals that comprise 90 percent of all discharges in the U.S. and include patients, regardless of insurance type.
The top 5 percent of hospital stays averaged about $18,000 in charges per day in U.S. hospitals in 2008, according to the AHRQ. Hospitals charges for the most expensive stays tended to be for patients who were getting treated for septicemia, or blood infection, hardening of the arteries and heart attacks.
The average cost for the most expensive patient stays was based on the top 5 percent of stays by cost, or about 2 million inpatient stays. The stays lasted just under three weeks (19 days). The hospitals charged on average $191,984 for those stays.
Compared with the less expensive visits, patients on more expensive hospital stays also:
Were much sicker. They were about 10 times more likely to experience extreme loss of function (39 percent vs. 4 percent).
Faced a greater risk of dying in the hospital (9 times more likely to be in the highest category for risk of death in the hospital (28 percent vs. 3 percent).
Were older. Their average age was 59 vs. 48.
The most commonly listed procedures among the top 5 percent were blood transfusion (28 percent), respiratory intubation and mechanical ventilation (27 percent) and diagnostic cardiac catheterization/coronary arteriography (13 percent).
The most expensive hospital stays occur at a higher rate in the Northeast and West and least in the Midwest.
FierceHealthCare
10-18-2010
This finding comes from data in Agency for Healthcare Research and Quality's newly released report, Most Expensive Hospitalizations, 2008, which uses data from a database of hospital inpatient stays in all short-term, non-Federal hospitals. Data are drawn from hospitals that comprise 90 percent of all discharges in the U.S. and include patients, regardless of insurance type.
The top 5 percent of hospital stays averaged about $18,000 in charges per day in U.S. hospitals in 2008, according to the AHRQ. Hospitals charges for the most expensive stays tended to be for patients who were getting treated for septicemia, or blood infection, hardening of the arteries and heart attacks.
The average cost for the most expensive patient stays was based on the top 5 percent of stays by cost, or about 2 million inpatient stays. The stays lasted just under three weeks (19 days). The hospitals charged on average $191,984 for those stays.
Compared with the less expensive visits, patients on more expensive hospital stays also:
Were much sicker. They were about 10 times more likely to experience extreme loss of function (39 percent vs. 4 percent).
Faced a greater risk of dying in the hospital (9 times more likely to be in the highest category for risk of death in the hospital (28 percent vs. 3 percent).
Were older. Their average age was 59 vs. 48.
The most commonly listed procedures among the top 5 percent were blood transfusion (28 percent), respiratory intubation and mechanical ventilation (27 percent) and diagnostic cardiac catheterization/coronary arteriography (13 percent).
The most expensive hospital stays occur at a higher rate in the Northeast and West and least in the Midwest.
FierceHealthCare
10-18-2010
Costs Of Veterans HealthCare Could Grow By 75%
More veterans and higher care costs in the next 10 years will result in billions of dollars more being spent on veterans' health care in the next decade, states a Congressional Budget Office estimate released Oct. 7.
Veterans Health Administration care costs will increase to between $69 billion and $85 billion by 2020, up from $48 billion in 2010. The number of veterans eligible for VA care -- now at 8 million -- is expected to grow by between 700,000 and 1.3 million veterans by 2020. The wide gap in the CBO estimates is due to different assumptions about several factors: the number of troops in Iraq and Afghanistan; the speed at which per-enrollee spending will grow; and the degree to which the VA relaxes enrollment restrictions. The lower forecast assumes that combined troop levels in both wars will decrease to 30,000 in 2013 and remain there until 2020, and that per-enrollee health care spending increases by 5% annually, about the same rate as in the rest of the U.S. health system.
The VA provides care to veterans at a level determined by veterans' military service. However, the VA also adjusts the care provided based on its annual congressional appropriations. VA spending increased by more than 9% on average each year between 2004 and 2009, reaching $44 billion, in 2009.
Amednews.com
10-18-2010
Veterans Health Administration care costs will increase to between $69 billion and $85 billion by 2020, up from $48 billion in 2010. The number of veterans eligible for VA care -- now at 8 million -- is expected to grow by between 700,000 and 1.3 million veterans by 2020. The wide gap in the CBO estimates is due to different assumptions about several factors: the number of troops in Iraq and Afghanistan; the speed at which per-enrollee spending will grow; and the degree to which the VA relaxes enrollment restrictions. The lower forecast assumes that combined troop levels in both wars will decrease to 30,000 in 2013 and remain there until 2020, and that per-enrollee health care spending increases by 5% annually, about the same rate as in the rest of the U.S. health system.
The VA provides care to veterans at a level determined by veterans' military service. However, the VA also adjusts the care provided based on its annual congressional appropriations. VA spending increased by more than 9% on average each year between 2004 and 2009, reaching $44 billion, in 2009.
Amednews.com
10-18-2010
Thursday, October 14, 2010
4,000 Social Security Numbers Possibly Exposed In VA Mismailing
Breaking news: A Veterans Benefit Administration office in Boston sent 6,299 benefit summary letters to the wrong addresses in September, more than half of them containing complete social security numbers, FierceGovernmentIT reports. Of the letters, 3,936 contained all nine digits of someone else's social security number, and 2,386 contained the VBA claim number of veterans based in the state. That's according to an update on data breaches the VA sends to Congress each month. The report blames the incident on a programming error.
FierceGovernmentIT
10-14-2010
FierceGovernmentIT
10-14-2010
When it comes to health plans, big spenders don't always deliver the best care, according to the new State of Health Care Quality report from the National Committee for Quality Assurance, a private, nonprofit organization dedicated to improving healthcare quality.
Here's one striking example: Vaccination rates for kids with private plans dropped by nearly 4 percentage points, while rates continued to rise for children on Medicaid plans in 2009. It's possible that a popular misconception that ties vaccines to autism has driven some parents away from evidence-based recommendations.
The report examined quality data from over 1,000 health plans that collectively cover 118 million Americans and compared types of plan by category.
There's been a drop in patient satisfaction with health plans and physicians, according to NCQA. For example, while 64 percent of members with Medicare plans said they usually or always manage to get needed care, only 53 percent of members with commercial plans felt the same. The latter was a drop from a high of 80 percent in 2005.
Another area where commercial plans lag behind Medicare and Medicaid plans is monitoring of drugs, such as Digoxin, diuretics, anticonvulsants and ACE inhibitors, which patients use for at least six months.
Medicare (83 percent) and Medicaid plans (77 percent) also fared better than commercial plans when one compares the share of members who received persistent beta-blocker treatment for six months after discharge with a heart attack diagnosis. But the report does note that commercial health plans have seen a dramatic rise in those rates, more than 34 percent since 1996 to 74 percent in 2009. "Ultimately," the report notes, "what gets measured gets improved."
FierceHealthCare
10-14-2010
Here's one striking example: Vaccination rates for kids with private plans dropped by nearly 4 percentage points, while rates continued to rise for children on Medicaid plans in 2009. It's possible that a popular misconception that ties vaccines to autism has driven some parents away from evidence-based recommendations.
The report examined quality data from over 1,000 health plans that collectively cover 118 million Americans and compared types of plan by category.
There's been a drop in patient satisfaction with health plans and physicians, according to NCQA. For example, while 64 percent of members with Medicare plans said they usually or always manage to get needed care, only 53 percent of members with commercial plans felt the same. The latter was a drop from a high of 80 percent in 2005.
Another area where commercial plans lag behind Medicare and Medicaid plans is monitoring of drugs, such as Digoxin, diuretics, anticonvulsants and ACE inhibitors, which patients use for at least six months.
Medicare (83 percent) and Medicaid plans (77 percent) also fared better than commercial plans when one compares the share of members who received persistent beta-blocker treatment for six months after discharge with a heart attack diagnosis. But the report does note that commercial health plans have seen a dramatic rise in those rates, more than 34 percent since 1996 to 74 percent in 2009. "Ultimately," the report notes, "what gets measured gets improved."
FierceHealthCare
10-14-2010
Subscribe to:
Posts (Atom)